Studying the Impact of Morbid Obesity and Massive Weight Loss on Skin Quality
Khaled Ahmed Sami Saber;
Abstract
Skin is the largest organ in the body and it has a unique anatomy that can adapt different conditions to perform its functions like protection, support and thermoregulation. It consists of an outer layer, the epidermis, which is a stratified squamous keratinized epithelium and underlying connective tissue layer, the dermis. The dermis has a superficial papillary layer separated from the epidermis by the dermo-epidermal junction, and a deep reticular layer and both contain collagen fibers, elastic fibers and different types of cells within a ground substance.
Collagen is the major skin extracellular matrix protein. In the young adult, the collagen in the papillary dermis appears as a framework of randomly oriented fine fibers, while that in the reticular dermis consists of large wavy, randomly oriented collagen bundles.
Elastic fibers in the skin give it the flexibility and extensibility needed, so it can deform and recoil easily, they are relatively a minor dermal component and with collagen fibers they give the skin its tensile strength.
Human skin is non homogenous, anisotropic, non linear viscoelastic and nearly incompressible. Its U.T.S ranges from 5 to 30 MPa. Many factors affect skin tensile strength like age as it decreses with age and also changes in body weight.
It is well known now that obesity is a major health problem worldwide. It`s increasing globally and now 50 % of population is considered as overweight or obese. Health consequences of obesity are physical, psychological and economic on the patient and society.
Many skin changes occur with obesity. It is usually dry, itchy, folded and more liable to infections specially at the site of skin grooves. These patients show poor wound healing especially with DM which is a common complication of obesity.
Many surgical options are available for weight reduction and they are categorized as restrictive, malabsorptive operations or combined. Each technique has its advantages and disadvantages but the most common consequence of these operations is massive weight loss.
Massive weight loss is the loss of 30 % of the total body weight or 50 % of the over weight and it usually follows bariatric surgeries leading to marked and well seen skin changes. There is always a deflated appearance with skin redundancy everywhere in the body. Skin appears thin, wrinkled, folded upon itself with marked laxity and loss of elasticity. It is not only an aesthetic problem but also causes problems with personal hygiene, sexual intercourse and finding suitable clothes and patients may become more annoyed than before by these changes.
It is the role of the plastic surgeon to address the changes that occur following massive weight loss and to put a plan to help the patient gets rid of the excess redundant skin to reach an aesthetically accepted shape and function with the minimal complications.
Despite there is a high rate of success in contouring procedures following massive weight loss, the results are always less than expected especially when compared to the same procedures done in normal weight persons. The skin of massive weight loss patients is relatively thin, less resistant and more liable to wound complications like delayed wound healing and wound dehiscence. One of the drawbacks is the skin redundancy that occurs following these procedures with relapses of different degrees.
All this was a motive to move to another level of study to the skin in morbid obesity and massive weight loss. While studies have investigated clinical outcomes in bariatric and post bariatric body-contouring populations, it is time to look on a more microscopic level to understand the effects of both obesity and massive weight loss on skin.
Unfortunately with these valuable clinical observations studies in literature on skin of massive weight loss patients are scanty, limited and somehow conflicting. That`s why we started to investigate skin quality in morbid obese and massive weight loss patients using a histological study combined with a biomechanical study.
The results of our study showed that skin of MWL patients is much weaker and less resistant to breakage than skin of normal weight and morbid obese patients with statistically significant difference in U.T.S.
We found also that morbid obesity didn`t affect the skin quality as it appeared almost normal with good collagen fiber thickness and density and only the elastic fiber network was impaired most probably due to excessive stretching applied to the skin. The results were clear in showing that skin of massive weight loss patients is much weaker and less resistant, lacks the integrity of epidermis and dermis.
From this study and reviewing the literature we can address changes that occur to the skin in morbid obesity and after massive weight loss on clinical, histological and biomechanical levels. And we can say that patients with massive weight loss should be treated differently than any other patients undergoing cosmetic contouring procedure, and we think that a multidisciplinary team is needed in the management of these patients.
These patients need special care to their skin which is usually dry (evidenced by thick keratin layer in histological study), weak, wrinkled, highly susceptible to inflammation and infections with problems in wound healing,and this care is better to be done by a dermatologist who can follow up and manage skin changes.
Proper assessment of the nutritional status of these patients not only regarding the major lab tests like hemoglobin and albumin levels,but special importance should be given to vitamins, minerals and trace elements are mandatory to achieve the best results from surgical intervention and it is much better if a dietician shares in the whole management before and after surgery.
The main damage to massive weight loss skin is seen to be in the collagen fiber network in the papillary and reticular dermis so special interest should be given to how to improve skin collagen in these patients before and after surgery and of course this will improve the results of the cosmetic procedures starting from wound healing to post operative final outcome. Although the literature shows many methods and devices to improve skin collagen network, none of these were tested on these patients and further studies should be done to assess their efficacy on improving collagen quality and concentration.
Collagen is the major skin extracellular matrix protein. In the young adult, the collagen in the papillary dermis appears as a framework of randomly oriented fine fibers, while that in the reticular dermis consists of large wavy, randomly oriented collagen bundles.
Elastic fibers in the skin give it the flexibility and extensibility needed, so it can deform and recoil easily, they are relatively a minor dermal component and with collagen fibers they give the skin its tensile strength.
Human skin is non homogenous, anisotropic, non linear viscoelastic and nearly incompressible. Its U.T.S ranges from 5 to 30 MPa. Many factors affect skin tensile strength like age as it decreses with age and also changes in body weight.
It is well known now that obesity is a major health problem worldwide. It`s increasing globally and now 50 % of population is considered as overweight or obese. Health consequences of obesity are physical, psychological and economic on the patient and society.
Many skin changes occur with obesity. It is usually dry, itchy, folded and more liable to infections specially at the site of skin grooves. These patients show poor wound healing especially with DM which is a common complication of obesity.
Many surgical options are available for weight reduction and they are categorized as restrictive, malabsorptive operations or combined. Each technique has its advantages and disadvantages but the most common consequence of these operations is massive weight loss.
Massive weight loss is the loss of 30 % of the total body weight or 50 % of the over weight and it usually follows bariatric surgeries leading to marked and well seen skin changes. There is always a deflated appearance with skin redundancy everywhere in the body. Skin appears thin, wrinkled, folded upon itself with marked laxity and loss of elasticity. It is not only an aesthetic problem but also causes problems with personal hygiene, sexual intercourse and finding suitable clothes and patients may become more annoyed than before by these changes.
It is the role of the plastic surgeon to address the changes that occur following massive weight loss and to put a plan to help the patient gets rid of the excess redundant skin to reach an aesthetically accepted shape and function with the minimal complications.
Despite there is a high rate of success in contouring procedures following massive weight loss, the results are always less than expected especially when compared to the same procedures done in normal weight persons. The skin of massive weight loss patients is relatively thin, less resistant and more liable to wound complications like delayed wound healing and wound dehiscence. One of the drawbacks is the skin redundancy that occurs following these procedures with relapses of different degrees.
All this was a motive to move to another level of study to the skin in morbid obesity and massive weight loss. While studies have investigated clinical outcomes in bariatric and post bariatric body-contouring populations, it is time to look on a more microscopic level to understand the effects of both obesity and massive weight loss on skin.
Unfortunately with these valuable clinical observations studies in literature on skin of massive weight loss patients are scanty, limited and somehow conflicting. That`s why we started to investigate skin quality in morbid obese and massive weight loss patients using a histological study combined with a biomechanical study.
The results of our study showed that skin of MWL patients is much weaker and less resistant to breakage than skin of normal weight and morbid obese patients with statistically significant difference in U.T.S.
We found also that morbid obesity didn`t affect the skin quality as it appeared almost normal with good collagen fiber thickness and density and only the elastic fiber network was impaired most probably due to excessive stretching applied to the skin. The results were clear in showing that skin of massive weight loss patients is much weaker and less resistant, lacks the integrity of epidermis and dermis.
From this study and reviewing the literature we can address changes that occur to the skin in morbid obesity and after massive weight loss on clinical, histological and biomechanical levels. And we can say that patients with massive weight loss should be treated differently than any other patients undergoing cosmetic contouring procedure, and we think that a multidisciplinary team is needed in the management of these patients.
These patients need special care to their skin which is usually dry (evidenced by thick keratin layer in histological study), weak, wrinkled, highly susceptible to inflammation and infections with problems in wound healing,and this care is better to be done by a dermatologist who can follow up and manage skin changes.
Proper assessment of the nutritional status of these patients not only regarding the major lab tests like hemoglobin and albumin levels,but special importance should be given to vitamins, minerals and trace elements are mandatory to achieve the best results from surgical intervention and it is much better if a dietician shares in the whole management before and after surgery.
The main damage to massive weight loss skin is seen to be in the collagen fiber network in the papillary and reticular dermis so special interest should be given to how to improve skin collagen in these patients before and after surgery and of course this will improve the results of the cosmetic procedures starting from wound healing to post operative final outcome. Although the literature shows many methods and devices to improve skin collagen network, none of these were tested on these patients and further studies should be done to assess their efficacy on improving collagen quality and concentration.
Other data
| Title | Studying the Impact of Morbid Obesity and Massive Weight Loss on Skin Quality | Other Titles | دراسة تأثير السمنة المفرطة وفقدان الوزن الشديد على كفاءة الجلد | Authors | Khaled Ahmed Sami Saber | Issue Date | 2014 |
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